Non-degree Application Verification of Student Record Form

Undergraduate Non-degree Verification of Student Record

To be Completed by Officials at the Student's Home/Most Recent Institution

Directions to school officials:

This form is used for all non-degree applicants, including guest and dual-enrollment applicants. It is to be filled out by the registrar or designated agent where the applicant is presently enrolled, or by the high school counselor for dual-enrollment applicants. If the student is not now enrolled in college and is seeking guest or non-degree admission, the registrar of the last college attended should complete this form.

Questions? Call us at 734-764-7433.

1. What type of admission is the student applying for?

Dual Enrollment (High School Student)

Guest or Non-degree (College Student)

2. Student Name

Last (Family)

First

Middle

3. Student U-M ID (if known):

4. Student U.S. Social Security Number:

5. Student Gender:

6. Student Birthdate:

7. I certify that the student named above is currently or was enrolled at:

8. This student's last term of registration was:

9. This student has exhausted coursework available in the following department:

9. How many semester/quarter credit hours has this student earned to date, and how many credit hours are needed to graduate?

Earned:

Type:

Required to graduate:

10. This student sat for the following AP exam(s) and earned the following score(s)
(If none, enter "n/a")

10. Please check the appropriate items listed below:

This student has graduated.

Date of graduation:

This student is in good standing and eligible to return.

This student has below a 2.0 ("C") average.

Current GPA:

This student is on probation.

Eligible to return?

Yes

No

This student has been requested to withdraw.

11. By my signature, I certify that all the answers I have provided on this form are complete and accurate to the best of my knowledge. I understand that falsification or omission of information or credentials may result in the revocation of the student's admission.

Name

Click to Sign...

Title

Institution

Street Address

Country

Street

City

Region

Postal Code

Email

Phone